Medical Examiner

What Actually Works to Get People Vaccinated

For many, getting their questions answered and setting up an appointment is no small thing.

Five needles are seen jabbed into different parts of a U.S. map.
Photo illustration by Slate. Photos by Getty Images Plus.

America is awash in vaccines. After a winter and spring where it was very, very difficult to get an appointment, we now have plenty of doses to go around. Kids over 5 can get shots, and the FDA even greenlit boosters for older teenagers last week. Immunizations may be critical to subdue the omicron variant, as many experts believe they will still protect against severe disease and that a booster will likely reduce the chances you’ll play a role in transmitting the virus to others. And yet, about 40 million adults remain unvaccinated—which may turbocharge a deadly surge that could push America north of a million cumulative deaths by this spring.

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The unvaccinated are reachable—at least a very good chunk of them. According to an October census report, 53 percent of the unvaccinated were still open to the shot. Of those willing to be vaccinated, according to a report by the COVID States Project, most had concerns about vaccine safety or side effects. But nearly 40 percent also cited logistical issues such as travel to a vaccine site, or being unable to take time off work. In other words: They just haven’t been able to get around to it. “We hear about these people who don’t want the vaccine because they’re going to track us with a microchip,” said Dr. Jannette Berkley-Patton, a professor of biomedical and health informatics at the University of Missouri–Kansas City School of Medicine and director of the university’s Health Equity Institute. But there’s this whole other group of people, she said, “who aren’t necessarily ‘no-to-vaccinate’ they are ‘slow-to-vaccinate.’ Traditional modes of public health communication aren’t going to reach them.” So how do you reach them? “We’ve got to hit the sidewalks.”

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Berkley-Patton’s own sidewalks crisscross Kansas City’s East Side, which consists of predominantly Black neighborhoods. Berkley-Patton grew up in one of those neighborhoods and for the past 15 years has leveraged her professional expertise and deep community connections to address health inequities in conditions ranging from HIV to diabetes. In the past two years, Berkley-Patton has secured $10 million in federal grants to battle COVID-19 specifically, with her latest efforts focused on increasing access to vaccines in some of Kansas City’s most socially vulnerable ZIP codes.

In February of 2021, East Side communities were getting left behind in the race to vaccinate, with some of the lowest rates in the city—despite Black Americans in Kansas City being almost twice as likely to die of COVID as white Kansas city residents are. To increase vaccination in these areas, Berkley-Patton launched a project called Our Healthy KC Eastside. She selected four people to helm her efforts: a faith leader, a youth association leader, a neighborhood association leader, and a business leader. Each of those leaders worked with the University of Missouri–Kansas City to recruit up to 15 existing organizations or entities in their sector—churches, restaurants, a local Boys & Girls Club—to help people sign up for vaccines. Each of these organizations identified two to three of their members to serve as community health liaisons. Berkley-Patton’s program trained them to encourage people to sign up for vaccination and, in the logistics of coordinating a vaccination event, armed them with answers to common questions about the shot and the virus. All told, nearly 60 organizations and an army of volunteers are working on the ground to get shots into arms. “I call it a machine,” Berkley-Patton said. The original goal was to vaccinate 5,000 residents, but Berkley-Patton’s “machine” is at 9,000 and counting. Today, about 75 percent of adults in those ZIP codes are vaccinated, according to the city’s data dashboard, compared with the citywide average of about 50 percent.

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Berkley-Patton said that community-embedded vaccination clinics give the slow-to-vaccinate a chance to ask questions of people they trust. “We made sure the community—church members, youth peers, business owners—were the ones actually meeting and talking with their neighbors.” A lot of people, she noted, aren’t really vaccine-hesitant in the way you might imagine—that is, they aren’t actively resistant to getting the shot. They just have questions, but may not have a health care provider: “We can say, ‘Hey, we have a physician right here.’ A lot of these people don’t have opportunities to meet with a doctor or pharmacist for 20 minutes to ask questions.” After talking to a doctor, she said, most people’s concerns—usually about side effects or vaccine safety—were allayed. At this stage of the pandemic, Berkley-Patton said, there may be no way forward but these labor-intensive community efforts, which involve one-on-ones or small group discussions with trusted community members. “We had a Garth Brooks concert at Arrowhead Stadium [with 70,000 attendees], and they set up one of these huge vaccination events, and I think they vaccinate, like, 35 people? We’d see over 60 people get vaccinated at a single small community event.”

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But answering questions doesn’t get at the simplest reason many people won’t get vaccinated: time. Those most vulnerable to COVID are more likely to be lower-income essential workers—people who can’t work from home, who often juggle two or three low-paying jobs with little security, living paycheck to paycheck. Plus, if they had tried to get a vaccine earlier in the rollout, they may well have been met with a clogged hotline. “If you have a 15-minute break, you can’t be on hold for an hour,” said Dr. Cristina Alonso, health equity director at the Boston-area community organization La Colaborativa. “You need to get your appointment and that’s it.” La Colaborativa, founded in 1988 to serve Boston’s lower-income suburbs, took a boots-to-the-ground approach to tackle this issue. The organization trained “health promoters” to walk the streets, knocking on doors and going to businesses such as restaurants, factories, and packing centers. They carried iPads with direct access to vaccine appointment slots in city clinics.

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This booking system allowed people to avoid phone conversations about personal information that might make them nervous, noted Alonso. This can be a barrier for undocumented immigrants in particular: “Some are like, ‘Why are you asking me all this information? How is this information safe?’ So we are saying, ‘You can just come Saturday at 10 a.m., no ID necessary.’ And that was key—a vaccine without all the layers of bureaucracy that the rest of the state or other health systems were asking people to navigate.” It seems to be helping. In the suburb of Chelsea, where efforts are concentrated, 92 percent of everyone over age 12 is fully vaccinated—much higher than rates in neighboring cities.

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Another strategy is to bundle vaccination with other community services—what Alonso calls a “wraparound” approach. Vaccine appointment assistance is offered at the same locations that provide boxes of food. Volunteers already walk the lines asking if people need eviction help or are in an abusive situation at home or at work—and connect them to what they need. The vaccine is just one more service to offer. “We often expect the most vulnerable and the most disadvantaged to spend their day navigating social services,” said Alonso. The system makes receiving help very, very inconvenient: “We want them to go to one office for their housing support, another office for their SNAP, another office to report their husband’s violent behavior, another office for their vaccine, another office to apply for health insurance and check up on their medical bill that they don’t understand,” Alonso said. “People are going to prioritize what’s most important. Obviously food and housing are going to be more important than a vaccine. So when you separate access to a vaccine from all of the other tragedies that people are navigating, that’s a barrier in and of itself.”

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There’s lately been a lot of talk among pundits about pandemic “off-ramps” and returning to “normalcy.” There is fury at the unvaccinated for prolonging the wait. This view might be understandable if you assume the unvaccinated are affluent political rivals duped by medical charlatans and YouTube mountebanks. Some of them certainly are. But pleas to “trust science” and “just get the shot already” start to sound a bit more tone-deaf when you consider that members of the unvaccinated population are just as likely to be the essential workers that this same work-from-home crowd depends on. And even as it’s very annoying or even quite scary for the privileged to worry about breakthrough infections, the chattering classes are not the people whose lives are, on balance, most at risk.

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Here’s a startling fact: Of the nearly 400,000 Americans who died of COVID-19 in 2020, only 3,746 of them, or a mere 1 percent, were college-educated non-Hispanic white individuals between 25 and 64 years old. If college-educated white Americans between 25 and 64 years old died at the same rate as people of color with a high school education or less in that same age range, then 45,340 would have died—a 1,110 percent increase. According to a recent study, if people of color between 25 and 64 years old experienced the same death rates as educated white people, the number of deaths would have been slashed by 89 percent, saving about 40,000 lives in 2020 alone. (Justin Feldman, a social epidemiologist at Harvard and a first author on that study, helped me crunch the numbers in this paragraph). If all people in America had experienced the same death rates as educated white people did, almost 200,000 lives would have been spared.

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In some ways, these past two years were the great health transfer of a generation. Despite all the praise heaped upon essential workers in 2020, all the banging on pots and pans, many could still face down omicron unvaccinated. (Preliminary evidence suggests that vaccines—especially a third dose—will offer protection against severe outcomes, even with omicron.) So what are the work-from-homers to do? I spoke to S. Mitra Kalita, who lives in Jackson Heights, one of the hardest-hit neighborhoods in New York City, where 1 out of every 158 people has died of COVID-19. As the pandemic devastated her neighborhood, Kalita, at the time a senior vice president at CNN, realized that “the 20-block radius around your house never mattered more.” That year, she quit her job and founded Epicenter NYC, a hyperlocal news and community organization that recently received a city grant to boost vaccine uptake in underserved communities.

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Kalita would like to see less talk about a return to “normal” and instead an urgency to vaccinate the millions who are willing to receive one, or get boosters into the arms of the most vulnerable: “We need the same mindset as back in the winter or spring of this year in terms of how we were talking about vaccines and volunteering to try to help people get them.” Even if you don’t go so far as to start an organization like Kalita’s, you can still volunteer—which could be as simple as posting flyers, helping people schedule appointments and reach vaccine clinics, or advocating for equity-driven pandemic policies (this will take a little Googling around, to find one local to you). Or, if you don’t have the time but do have the money, you can make vaccine equity part of your end-of-the-year charity goals by donating either to local community organizations or international vaccine equity initiatives. At a minimum, you can use the tools we already have—getting boosted, wearing a good mask, using rapid tests, and isolating—to reduce spread in the omicron era. But, as Kalita pointed out to me, these efforts aren’t some munificent acts of benevolence that the privileged should pat themselves on the back for—they’re a moral obligation. “You aren’t giving back because you have,” she said, “you’re giving back because you took.”

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